A medical student’s prescription for primary care

By gerencherk

Primary-care physicians seem to have both the best and worst of the U.S. health-care system wrapped up in their job descriptions. As general internists, family doctors or pediatricians, they can lead fulfilling careers helping patients with a wide variety of medical needs and establishing trusting relationships with entire families. But they also have to speed through office visits, haggle with insurers and pore over paperwork while bringing home earnings vastly lower than those of their subspecialist colleagues.

I caught up with a future PCP to see what inspires and scares him most about his chosen career as the primary-care shortage intensifies and U.S. lawmakers prepare for the final round in this year’s historic health-reform debate.

Ryan Van Ramshorst, a fourth-year medical student in Houston, Texas, is a National Health Service Corps scholar who’s working towards being a general pediatrician. After graduating from medical school next spring, he will go on to a three-year residency program, where he will become the first doctor in his family.

The National Health Service Corps offers scholarships and loan repayment programs to students training to become PCPs, dentists, nurse practitioners, certified nurse-midwives or physician assistants in exchange for their commitment to practicing for two to four years in areas deemed short of those health professionals. More than 30,000 primary-care clinicians have served in medically underserved areas since the program began in 1972. Read more about the National Health Service Corps here.

Van Ramshort, age 25, acknowledged the problems likely to arise if and when a primary-care shortage meets the added demand of newly insured patients seeking care. But like the experts I spoke with for my column, he said the mismatch is no reason to reject or scale back efforts to extend health insurance to more Americans. In fact, a health-care overhaul would start addressing the mismatch by increasing residency training slots for PCPs and raising their pay. Since the legislation wouldn’t begin phasing in until 2013 at the earliest, the lead time may help in strengthening the pipeline.

“It’s kind of a chicken and egg issue,” Van Ramshorst said of the PCP shortage. “I think we can do a better job as a profession of teaching why it’s important and incentivizing it financially and making sure students understand how they can best serve.”

He said he’s seen many of his classmates opt for better-compensated subspecialties such as dermatology and opthalmology. While the money and lifestyle those professions offer are hard to ignore, those factors haven’t won him over from his preference for holistic care of the whole patient, even though office visits are reimbursed at a much lower rate than procedures under the current payment structure.

“I truly went into this to serve,” he said.

Van Ramshorst, an active member of the American Medical Student Association, said he’s been following the health-reform debate with interest. If a bill passes it won’t be perfect, he said, but will still count as progress.

“It’s been a long time coming that all Americans have access to high-quality health care,” he said. “It’s a right, especially for our nation’s children. I would really like to be able to practice in a world where everyone has equal access to health care that they so very much need and deserve.”

Van Ramshorst has worked with uninsured children and seen how barriers to care can affect them. A simple ear infection that goes untreated because the family doesn’t have a clinic to go to or the money to afford coverage or medication can turn into a more serious bone infection called mastoiditis, for example.

“It’s excruciating for the kids,” he said. “Ear infections are painful enough.”

Fortunately, many cases of mastoiditis are treatable — although they often involve intravenous antibiotics as opposed to simpler oral ones — and children typically make a full recovery. “It’s those successes that really keep me motivated.”

What scares him about his chosen path? Van Ramshorst said a lack of autonomy over how much time he spends with patients is high on the list. The brief length of the average office visit reflects pressure to see 30 to 40 patients in a day, an amount he says is not uncommon for PCPs.

“I’m still learning, but I cannot comprehend how you can do everything and be the best advocate for your patient in 15 minutes,” Van Ramshort said. “It’s up to us as future health professionals and future leaders to make sure that changes.”

About Health Matters

Health Matters is a blog-style round-up of news and analysis concerning consumer health and the business of health care. The lead writer is MarketWatch reporter Kristen Gerencher, who also writes the Vital Signs column. Andrea Coombes and Jonathan Burton contribute editing. Gerencher won a 2006 explanatory journalism award from the Society of Professional Journalists-Northern California for a series she did on health savings accounts.